Monthly Archives: October 2009

The Daily Record had an article about attorney F. Paul Bland, who represents a neglected nursing home resident, urging Maryland’s highest court to let her take her fraud claims against a Baltimore nursing home to trial, rather than to arbitration as the health care facility wants. Addison, who suffered a stroke in September 2005, says the nursing home delayed filing her Medicaid application so it could continue charging her a higher daily rate for several months. The delay eventually cost her more than $70,000. She also alleged that a nursing home employee put her in touch with people who tried to buy her home for far less than its value.

“Ms. Addison should be permitted to have this trial go forward while she is alive,” he told the Court of Appeals on behalf of his client, Beulah Addison. A circuit court judge ruled in 2007 that Addison could not be forced to arbitrate her claims, but his decision was reversed last year by the Court of Special Appeals.

Lochearn Nursing Home LLC’s lawyer, Melvin Sykes, defended that action. Bland, though, argued that the Court of Special Appeals should never have heard the case, because the judge’s ruling was not subject to appeal under Maryland’s laws of civil procedure.

The dispute has spurred interest from groups who oppose arbitration provisions in consumer contracts, saying they compel unwary purchasers into forfeiting their right to their day in court — a “sacrifice [that] falls particularly hard on economically vulnerable populations,” according to the Baltimore-based Public Justice Center.

“Mandatory pre-dispute arbitration agreements that were once confined to sophisticated commercial entities are now routinely imposed via form contracts on consumers and employees who often have little bargaining power and few alternatives,” C. Matthew Hill wrote in the Public Justice Center’s brief to the Court of Appeals. Joining the brief were the Maryland Employment Lawyers Association, Maryland Consumer Rights Coalition Inc. and the National Association of Consumer Advocates.

NY Times has a blog called The New Old Age. Recently, they had an entry by Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions” regarding nursing homes. The entry begins with a story about Sharon Kenney’s mother, Eunice. Eunice was waiting, and waiting, for an aide to answer her call bell and help her to the bathroom. Her daughter stayed on the phone with her for 45 increasingly desperate minutes. Finally Ms. Kenney hung up, called the desk nurse and asked that someone be sent to assist her mother. The ensuing conversation, as she recalls it:

Nurse: “We’re really busy and we have a lot of residents here. You’ll have to wait your turn.”

Ms. Kenney (after long pause): “That’s not the answer I was expecting. The answer I was expecting was, ‘I’m so sorry, we’ll send someone right down there.’”

Nurse: “I only have one person on that wing. She needs to wait.”

Ms. Kenney: “Maybe you could go down and help her. Do I have to drive over there and help her myself?”

Ms. Kenney takes meticulous notes of the neglect. Her motto for dealing with the staff: “Be as polite as possible. But relentless.”

Virtually all nursing homes are chronically short-staffed, with too few aides and nurses scurrying to help too many residents, who are more impaired and suffer higher rates of dementia than their peers a couple of decades ago.

The article goes on to discuss Cynthia Dyer-Bennet. She grew frustrated when the aides caring for her mother in a dementia facility outside San Francisco seemed to routinely neglect brushing her teeth. “I could tell because her toothbrush was always bone-dry,” Ms. Dyer-Bennet said. The staff denied any problem. “They’d say, ‘We did brush her teeth.’ I’d say, ‘No, look, here’s her toothbrush — it’s dry at 9:30 in the morning.’ They’d lie to me.” She understood that with three aides caring for 27 residents, the staff was doing its best. She knew, firsthand, that with an Alzheimer’s patient, brushing teeth can take 20 minutes. But she persisted, citing what she saw as broken promises about diet and activities, as well as oral hygiene. “It reached the point where the caregivers didn’t want to see me because I was waving a toothbrush, and the administrators didn’t want to see me because they didn’t want to hear complaints,” Ms. Dyer-Bennet said. She eventually moved her mother elsewhere.

Family members who perceive conflict with staff have significantly higher levels of depression, according to a 2007 study conducted in 20 upstate New York nursing homes. And interviews with nearly 700 nursing home nurses and nursing assistants revealed that conflict with family members increases staff burnout and lowers job satisfaction, which contributes to the sky-high staff turnover rates that already plague many nursing homes.

Long term Living Magazine had an interesting article on the increase of dementia based on the 2009 World Alzheimer Report. Perhaps the increase is caused by better diagnostics and understanding of the condition. According to the World Alzheimer Report, released by Alzheimer’s Disease International (ADI), an estimated 35.6 million people worldwide will be living with dementia in 2010. This is a 10% increase over previous global dementia prevalence reported in 2005. According to the new report, dementia prevalence will nearly double every 20 years, to 65.7 million in 2030 and 115.4 million in 2050.

"The information in the 2009 World Alzheimer Report makes it clear that the crisis of dementia cannot be ignored," says Debbie Benczkowski, Interim CEO of the Alzheimer Society of Canada. "Unchecked, dementia will impose enormous burdens on individuals, families, healthcare infrastructures, and global economy."

The report also focuses on the impact of dementia. For example, statistics cited in the new report suggest that 40% to 75% of caregivers have significant psychological illness as a result of their caregiving, and 15% to 32% have depression. This article is interesting because it states that 40-75% of caregivers for people with Alzheimer’s have significant psychological illness as a result of their caregiving. This statistic is a good explanation when nursing homes try to claim that the resdient’s family should have cared for the person at home despite their lack of education and expertise. It is also indicative of the need for additional staffing for dementia residents so burn-out, turnover, abuse, and neglect do not occur.

TriCities.com had an article about the case of Anne Brightwell. She died in a hospice bed June 16 after months of screaming over a fractured left femur that would not heal. Her upper leg bone shattered Feb. 6, when a hammock sling, used by Cambridge House nursing home staff to hoist her from a bed to a wheelchair, snapped. A medical examiner listed the broken femur as the cause of death on Brightwell’s death certificate.

The fall could have been prevented. The nursing home had a history of using aging and tattered slings, but throwing newer equipment into use only when Tennessee Health Department inspectors arrived. Three former Cambridge House employees say administrators hid daily-use equipment from inspectors, only to later pull it out after tucking away the newer items until the next state visit.

Cambridge House is part of a national chain of for profit nursing homes owned by AltaCare Corp., based in Alpharetta, Ga. A letter faxed to the newspaper by Cambridge House confirmed “an incident involving use of clinical equipment, resulting in an injury that was treated in accordance with accepted clinical standards of practice.”

“Granddaughter Amy Shell noted in an interview that Brightwell lived through her twilight years without ever needing prescriptions for such common elderly ailments as high blood pressure or cholesterol. Brightwell landed in a Cambridge House bed to rehabilitate an ankle she fractured at her Bristol, Tenn., home, where she lived alone, except for nightly visits from relatives. Shell said Brightwell likely would have left the nursing home after rehab was complete.

Expectations changed the day the hammock sling snapped, with Brightwell awkwardly slamming to the floor on her left side. Because of her age, the bone would not heal on its own. And, at her age, surgery to amputate the leg might have killed her. The only option left for the aging matriarch was to rely on pain pills. Family members said it didn’t offer much help. “Mom would lay in bed and say ‘Help me please, help me God, Jesus,’ and this would go on for hours,” Countiss said.

Former nursing aide Dickie Norris recalled in an interview the threadbare condition of the three hammock swings used at Cambridge House from last year until soon after Brightwell’s fall.
“They were frail … like a worn out pair of jeans,” said Norris, who joined the nursing home in June 2008 and left in March. The lifts remained in use until four weeks after Brightwell’s fall. Norris said he was lifting a patient out of bed and had him in midair when an administrator appeared and told him to get the patient down and hand over the sling. “Then they ordered slings, but they wouldn’t work on the (pulley) machines,” Norris said. “We couldn’t get people up for physical therapy for weeks.”

Former nursing aide Brian Gross, who worked at the nursing home from May 2008 until October 2008, did not trust the slings. “In those slings, I wouldn’t want to be lifted in it, and I weigh only 140 pounds,” he said. Gross estimated that many of the nursing home’s patients weigh more than 200 pounds. Gross recalled that the slings shown at inspection were slightly used, but in much better shape than the ones kept in daily circulation.

The hammock slings might have been discarded months earlier, had state inspectors seen them. Past nursing home employees said the Cambridge House administration went so far as to hide shabby equipment during health department inspections. Former nursing aide Tony Apple, in a sworn deposition provided by lawyer Parke Morris, said that administrators pulled out newer equipment specifically for annual state inspections. “Once the state inspection was over, the old slings came out,” Apple said in the deposition.

Not only were the hammock slings in ill shape, said Shawna Caudill, a former Cambridge House nursing manager, but the bedsheets, towels and other linens showed considerable wear, too.
Caudill, who joined Cambridge House in April 2007 and left in November 2008, said the administration purposely overlooked the shabby quality of equipment. “The faulty equipment was definitely brought up at many meetings, but it all boiled down to cost,” Caudill said. One administrator’s “exact words were to put on my big-girl panties and deal with it.”

The Sun-Sentinel had a scary story about convicted felons working in Florida’s nursing homes. The articles states that Florida seniors and disabled adults too frail to live on their own have been beaten, neglected and robbed by caregivers with criminal records. More than 3,500 people with criminal records — including rape, robbery and murder — have been hired to work at nursing homes. Hundreds more slipped through because employers failed to check their backgrounds or kept them on the job despite their criminal past.

Florida has a patchwork of controls for checking caregivers of the elderly that seems to put more emphasis on protecting against embezzlement than safeguarding patients. Inconsistencies in state law are glaring — facility owners, administrators and people who handle money require a nationwide FBI check, but not employees caring for patients. With some exceptions, they are checked only for crimes in Florida.

Under Florida law, certain crimes disqualify someone from working with seniors or the disabled unless they obtain an exemption by showing evidence of rehabilitation. Until this year, the disqualifying offenses did not include financial crimes that can lead to abuse and exploitation. An expanded list takes effect Thursday — eight years after a committee of prosecutors and state regulators recommended adding crimes such as burglary, fraud and forgery.

Patients and their families have no way of checking employees’ criminal histories. Personnel files are confidential, as they are for any private business. State inspectors are supposed to ensure screening requirements are met but inspect nursing homes on average only once a year and assisted living facilities every other year. Inspection data shows the system fails to weed out employees with disqualifying records and is slow to remove them once hired.

"When you’re under the gun of trying to find a place for your relative and they’re in the hospital and they’re dying, it’s the last thing on your mind as to whether it’s a safe facility," he said. "You assume with the state regulating them, that’s a given."

This guest article was written by Amy S. Cook, who regularly writes on the topic of lvn to rn . She welcomes your comments and questions at her email address: amy.cook@rediffmail.com.

It’s not the easiest of times when you know your loved one has to be admitted to a nursing home because you don’t have the time or energy to provide them with the care they need. So you look around for the best nursing home that will suit their needs and admit them. You may have relegated their daily care to someone else, but there is still a lot you can do for your loved one even though you visit them only once in a while. To start with, you could:

• Choose a nursing home that is close to you: You must make it a point to visit your loved one at least once a fortnight or more. And the easiest way to keep to this rule is to choose a nursing home that is close to where you live. If you’re able to drive down and back in half a day or less, you’re more likely to keep your visits and not find excuses to get out of them. Visits from loved ones mean a lot to patients in nursing homes, especially the ones who are still of sound mental health.

• Talk to the staff there to see how they are doing: Ensure that you talk to the staff at the facility to see how your loved one is doing there. If you get the vibe that all is not well, make enquiries and see if it is a problem that you can resolve. If not, consider shifting your loved one to another nursing home. It’s important that they are comfortable and happy with their living conditions. Ask your loved one for their opinion too, and don’t dismiss their grumblings and complaints as the rambling of old people.

• Look around their room and see if it is clean: The nursing home staff usually does a good job of cleaning your loved one’s room, but there is more to cleanliness than meets the eye. Help your loved one keep their personal belongings clean each time you visit – wash their combs, wipe down objects they use often, like their remote control, pager, mobile phone or any other technological gadget, and so on. It makes a huge difference to live in hygiene and have someone help you with it.

• Help them personalize their rooms: Your loved one will think of home and family often, so help them preserve their memories with photographs and other personal memorabilia. You could also decorate their room with their favorite accessories so that they feel at home even though they are in a nursing home.

Nursing homes must be homes away from homes if your loved one is to feel comfortable there. So do what you can to ensure that this is possible.

L.A. Times had an article about the obvious importance of staffing in providing quality care in nursing homes. The cornerstone to quality care in a nursing home is staffing. Those with larger staffs tend to have less turnover, more stability and are more likely to meet the needs of all the residents.

"There is some very persuasive data showing staff simply can’t perform all of the responsibilities they have unless there is an adequate ratio of staff to residents," says Janet Wells, policy director for the National Citizen’s Coalition for Nursing Home Reform, a reform-activist-advocacy organization. Homes should be staffed to provide at least 3 1/2 to four hours of care per resident in a 24-hour period, says Larry Minnix, chief executive of the American Assn. of Homes and Services for the Aging, a nonprofit organization that represents not-for-profit elder-care facilities. Some may need to offer four to five hours daily depending on the conditions of the residents.

To assess staffing levels, Pat McGinnis, executive director of California Advocates for Nursing Home Reform, recommends visiting at a time when a facility is most likely to have maximum staff on duty (like at lunch, the biggest meal of the day). Telltale signs of understaffing include diners with food trays who are not eating because they are not receiving necessary assistance, residents sitting idly in common areas or their rooms with nothing to hold their attention, call buttons going unanswered, and development of pressure ulvers.

Visiting during mealtime is also a good way to gauge food quality. Weight loss can be dangerous to the elderly, so food should look and smell appetizing. Some of the more progressive homes have buffet lines rather than the "school lunchroom program," in which residents shuffle through with trays, Minnix says. "Food is the most looked-forward-to institution for many people, especially those confined to a home," he says. "You should ask about snacks and what kind of weight loss-weight gain program they have."

The Oakland Tribune had an article about how many nursing homes refuse to carry insurance in an effort to limit their liability and fail to compensate residents who are injured or die as a result of their abuse or neglect. The article discusses the case of Grover Brown. Brown was 37 years old who developed pressure sores soon after arriving at the High Street Care Center in East Oakland. One of the sores never healed properly. But once the wound did begin to fester, he wasn’t moved, washed, monitored or medicated with antiseptic. The wound got worse, Surgeons had removed his tailbone because the wound had festered without treatment. Even as the sore turned green and smelled foul indicating infection, the nurse in charge at the time told an aide that was the way "it was supposed to smell," according to Department of Public Health records. The infection ate away at the bone through to the marrow despite repeated treatment orders from physicians to the staff of High Street Care Center.

Brown is suing High Street Care Center, which had a long list of citations from the Department of Public Health — 164 between 2004 and 2008. The facility was owned until December 2008 by Trinity Health Systems, whose president, Randal Kleis, has operated about a dozen facilities across the state under several corporate names. But Brown likely won’t see more than a token settlement from High Street Care Center because skilled-nursing facilities, nursing homes and assisted-living care facilities — charged with caring for the most vulnerable — are not required to carry liability insurance. And Kleis’ other assets are untouchable because they were legally registered as separate corporate entities — a common way operators shield themselves and their profits, said Kathryn Stebner, a lawyer who has been representing victims of nursing home abuse since 1987.

The state Attorney General’s Office, which is California’s ultimate watchdog, has gone after fewer than a dozen problem nursing homes for elder abuse and neglect since 2000. That leaves private attorneys to pursue the operators — almost always after the damage has been done.

Medi-Cal began reimbursing facilities for the cost of liability insurance in late 2004 with the expectation that care would improve. But the decision whether to carry insurance was left to nursing-home owners. There was nothing to mandate the improvement.

The incident was not an isolated mistake. Brown’s lack of care was the consequence of an indifference to the health and safety of residents at the facility. High Street Care Center had a record of poor care, according to records from the Department of Public Health:

On Dec. 7, 2004, an 82-year-old woman at High Street Care Center was suffering from a bed sore that had penetrated through her tendons and muscles to the bone. She was taken to a hospital, where doctors found she weighed 65 pounds and described her as "extremely emaciated." She went to a new nursing home and immediately began gaining weight.

In January 2005, inspectors discovered that the supervisor of dietary services was not certified.

Just two months after being admitted in March 2005, a 54-year-old breast cancer patient who had trouble swallowing lost 23 percent of her body weight. She dropped from 117 pounds to 90 pounds by May 2, 2005. But staff told her family she was gaining weight.

In December 2005, inspectors described finding a cockroach crawling around the base of trash cans full of dirty diapers in one of the rooms. A resident told inspectors that they were crawling around "all the time."

In 2006, a 59-year-old woman told staff at the Center for Elder Independence, a community day care program for elders she attended for treatment, that a certified nursing aide at High Street Care Center had used a washcloth to cover the woman’s nose and mouth. When she cried out in pain for fear of being smothered, the aide hit her on the side of the head. A social worker alerted to the alleged abuse by High Street Care Center staff, also had reported the incident to the Public Health Department. The facility’s administrator told inspectors that although the aide denied the allegations, he fired the aide and "believed something had happened to the resident."

Kleis has settled at least two previous wrongful-death lawsuits in the past six years, court records show. In each case, Kleis asserted he was losing money and could not afford insurance.

The MacArthur Care Center, run by Kleis under the company name Trinity Health Systems, had an extensive record of problems and lawsuits. The Department of Public Health cited the facility for 79 deficiencies between 2004 and 2009.

AARP spokesman Mark Beach said every responsible business should have liability insurance especially those like nursing homes and skilled nursing facilities that take care of the most vulnerable and dependent people. It fosters accountability and ensures people are compensated when something happens even if an owner declares bankruptcy, he said.

The AP had an article about the federal program that identifies problem nursing homes. The program brings extra scrutiny to poorly performing nursing homes but leaves out hundreds of troubled facilities, investigators report. The Centers for Medicare and Medicaid Services identifies up to 136 nursing homes as "special focus facilities" subject to more frequent inspections because of their living conditions. In every state except for Alaska, there are between one and six such facilities. But investigators said four times as many homes, or 580, should be considered among the nation’s worst.

Sen. Herb Kohl, the chairman of the Senate Aging Committee, said it indicated to him that the special focus is too limited. At the least, he wants more explicit warnings about nursing homes as people study quality ratings on a Medicare Web site, Nursing Home Compare — http://www.medicare.gov/nhcompare

The report being released Monday also suggests adjusting the methods used to identify the worst performing nursing homes. The home now under special attention are the worst performing in their state. But not all states are created equal when it comes to nursing home quality. Comparing the homes nationally would ensure that scarce resources go to inspecting the nursing homes that truly need the most attention.

Some states have far more poorly performing nursing homes than are designated as special focus facilities. Investigators also found that the worst-performing ones tend to be for-profit facilities affiliated with a chain of nursing homes. They are more likely to be a larger facility, averaging 102 residents, while other nursing homes not identified as among the worst had 89 residents on average.

Nationally, there are about 16,000 nursing homes. So the 580 homes that GAO describes as the worst-performing represents almost 4 percent of the nation’s nursing homes.

David Leonhardt had a recent article in the NY Times discussing the need to lower medical malpractice as away to lower medical malpractice litigations. Seems like common sense to me.

The direct costs of malpractice lawsuits — jury awards, settlements and the like — are such a minuscule part of health spending that they barely merit discussion, economists say. But that doesn’t mean the malpractice system is working.

The fear of lawsuits among doctors does seem to lead to a wasteful treatment. Amitabh Chandra — a Harvard economist whose research is cited by both the American Medical Association and the AAJ — says about 3 percent of overall medical spending, is a reasonable upper-end estimate. At the same time, though, the current system appears to treat actual malpractice too lightly. Trials may get a lot of attention, but they are the exception. Far more common are errors that never lead to any action.

After reviewing thousands of patient records, medical researchers have estimated that only 2 to 3 percent of cases of medical negligence lead to a malpractice claim. Medical errors happen more frequently here than in other rich countries, as the Robert Wood Johnson Foundation recently found. Only a tiny share of victims receive compensation. Among those who do, the awards vary from the lavish to the minimal.

All told, jury awards, settlements and administrative costs — which, by definition, are similar to the combined cost of insurance — add up to less than $10 billion a year. This equals less than one-half of a percentage point of medical spending.

Research — into various surgical operations, for instance — has found less of evidence of defensive medicine. The problem is that just about every incentive in our medical system is to do more. Most patients have no idea how much their care costs. Doctors are generally paid more when they do more. Similarly, you would want to see more serious efforts to reduce medical error and tougher discipline for doctors who made repeated errors — in exchange for a less confrontational, less costly process for those doctors who, like all of us, sometimes make mistakes.

The goal, remember, isn’t just to reduce malpractice lawsuits. It’s also to reduce malpractice.